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Found 61 results
  1. News Article
    The death of a "vulnerable" transgender teenager who struggled to get help was preventable, a coroner has said. Daniel France, 17, was known to Cambridgeshire County Council and Cambridgeshire and Peterborough Foundation Trust (CPFT) when he took his own life on 3 April 2020. The coroner said his death showed a "dangerous gap" between services. When he died, Mr France was in the process of being transferred from children and adolescent mental health services (CAMHS) in Suffolk to adult services in Cambridgeshire. The First Response Service, which provides help for people experiencing a mental health crisis, also assessed Mr France but he had been considered not in need of urgent intervention, the coroner's report said. Cambridgeshire County Council had received two safeguarding referrals for Daniel, in October 2019 and January 2020, but had closed both. "It was accepted that the decision to close both referrals was incorrect", Mr Barlow said in his report. Mr Barlow wrote in his report, sent to both the council and CPFT: "My concern in this case is that a vulnerable young person can be known to the county council and [the] mental health trust and yet not receive the support they need pending substantive treatment." He highlighted Daniel was "repeatedly assessed as not meeting the criteria for urgent intervention" but that waiting lists for phycological therapy could mean more than a year between asking for help and being given it. "That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act," Mr Barlow said. Read full story Source: BBC News, 25 February 2022
  2. Content Article
    On 8 April 2020 the coroner commenced an investigation into the death of Daniel France, age 17. Danny was 17 years old and was living at a YMCA hostel. He was on medication for depression and had been referred to secondary mental health services. He had made previous suicide attempts. On 3 April 2020 he took his own life. The medical cause of death was asphyxiation by hanging and the conclusion was suicide.  Danny was a vulnerable teenager: he had left home and was living in hostel accommodation; he had changed his GP practice; he was trans, had changed his name and had been referred to the Gender Identity Clinic; he had recently been discharged from secondary mental health services in Suffolk and had been referred to mental health services in Cambridge; he had previously been under CAMHS and was now being referred to adult mental health services; he had diagnoses of anxiety and depression and had been prescribed medication; he had made previous suicide attempts and had long term suicidal thoughts He had been assessed by First Response Service but had been considered as not requiring urgent intervention. Safeguarding referrals about Danny were made to Cambridgeshire County Council in October 2019 and January 2020. Both referrals were closed and it was accepted that the decision to close both referrals was incorrect. In December 2019 Danny’s new GP referred him to Cambridgeshire & Peterborough NHS Foundation Trust (CPFT). He had been seen by the Primary Care Mental Health Services but was still awaiting assessment by the Adult Locality Team at the time of his death. 
  3. Content Article
    This report by Bliss, the UK’s leading charity for babies born premature or sick, found that young parents are often underprepared and under-supported when their babies are in neonatal care. Research by Bliss found that more than half of young parents felt they were not as involved in caregiving or decision-making as they wanted to be when their baby was born premature or sick. It also highlighted contradictory messages that young mothers are given throughout their pregnancy that their youth will be a protective factor, despite an increased risk of prematurity and neonatal mortality for babies born to mothers aged under 20. This myth leaves many young parents feeling unprepared, enhancing their feelings of shock and disbelief if their babies are born unwell.
  4. News Article
    Campaigners have called for a change in how epilepsy services are delivered after "alarming" new research revealed that nearly 80% cent of deaths in young adults could have been avoided. It comes as researchers behind the first ever national review into deaths linked to the condition warned that "little has improved in epilepsy care" despite previous findings of premature mortality. They describe the situation as a "major public health problem in Scotland", adding that deaths "are not reducing, people are dying young, and many deaths are potentially avoidable”. In particular, the Edinburgh University team found that adults aged 16 to 24 were five times more likely to die compared to the general population, a problem they said may be linked to the "vulnerable period of transition from paediatric to adult care". Overall, for adults with epilepsy aged 16 to 54, the mortality rate was more than double that for the age group as a whole, with as many as 76% of these deaths potentially preventable and the majority occurring among patients from the most deprived areas. Read full story Source: The Herald, 11 November 2021
  5. Content Article
    This report looks into the circumstances surrounding the deaths of three young adults; Joanna, Jon and Ben. They each had learning disabilities, were patients at Cawston Park Hospital and died within a 27 month period (April 2018 to July 2020). It highlights multiple significant failures in care, including excessive use of restraint and seclusion, overmedication of patients, lack of record keeping and the physical assault of patients. The report also makes a series of recommendations for critical system and strategic change, both at a local and national level.
  6. News Article
    A catalogue of failures among prison and health professionals has been highlighted in an investigation report into the death of a teenager’s baby after she gave birth alone in her cell at the largest women’s prison in Europe. The Prisons and Probation Ombudsman published the devastating report into the events in September 2019 at HMP Bronzefield in Ashford, Middlesex on Wednesday. The case was first revealed by the Guardian and the baby’s death triggered 11 separate inquiries. The report details a disturbing series of events that culminated with the young woman, who cannot be named, being in “constant pain” on the night of 26 September and eventually passing out while giving birth. According to the report the teenager "appeared to have been regarded as difficult and having a ‘bad attitude’ rather than as a vulnerable 18-year-old, frightened that her baby would be taken away”. Failings included: There was confusion among different health professionals about her due date. The day before her baby was born she told a prison nurse she would kill herself or someone else if the baby was taken away from her, but this information was not adequately shared. On 26 September she was put on extended observation, meaning she should have been regularly checked but this did not happen. She rang the bell twice at 8.07pm and 8.32pm that day. A call was connected then immediately disconnected at 8.45pm. She did not press the bell again. Checks by prison officers at 9.27pm and 4.19am revealed “nothing untoward”. It was left to two prisoners to alert staff to the fact that there was blood in her cell at 8.21am on 27 September. Prisons and Probation ombudsman Sue McAllister said: “Ms A gave birth alone in her cell overnight without medical assistance. This should never have happened. Overall, the healthcare offered to Ms A in Bronzefield was not equivalent to that she could have expected in the community.” The publication of the report has triggered multiple calls for an end to the imprisonment of pregnant women from the Royal College of Midwives, NGOs and academics in the field. Read full story Source: The Guardian, 22 September 2021
  7. News Article
    The UK's vaccine advisory body has decided not to recommend vaccines for healthy 12-15-year-olds, but it will offer vaccines to thousands more children with underlying health problems. Ministers will now seek more advice on extending the rollout based on factors such as school disruption. There is general agreement that this was a really tricky call to make. Bur The Joint Committee on Vaccination and Immunisation (JCVI) has focused squarely on the health benefits of vaccination to children themselves - not on the impact to their schooling or other people. Children's risk from Covid isn't zero but the chances of them becoming seriously ill from Covid are incredibly small. Deaths among healthy children are extremely rare - most have life-limiting health conditions. That means there needs to be a clear and obvious advantage to giving them a jab. However, a very rare side-effect of the Pfizer and Moderna vaccines has made that calculation a lot more complicated. Paul Hunter, professor of medicine at University of East Anglia, says there's been intense pressure on the JCVI and he can understand why they are being cautious. "I don't know what the answer is - I'm very close to the fence on this. There's not enough data to be absolutely certain." Read full story Source: BBC News, 4 September 2021
  8. News Article
    Younger adults and those living in poorer neighbourhoods and black people have the highest levels of vaccine hesitancy, new survey data from the Office for National Statistics has shown. The vast majority of Britons back the COVID-19 vaccines and are keen to be inoculated, with more than 9 out 10 people being positive about the jab. But the ONS said data from a survey between 13 January and 7 February revealed reluctance among less than 10% of the population. It found more than 4 in 10 of black or black British adults reported vaccine hesitancy, the highest of all ethnic groups, while adults aged 16-29 were most likely to report hesitancy, at around 1 in 6 or 17%. Adults living in the most deprived areas of England were more likely to report vaccine hesitancy at 16%, compared with 7% of adults in the least deprived areas of England. This has been evident in the take up of the vaccine among some deprived areas of the country which have struggled to vaccinate everyone in priority groups. Even among NHS and social care staff there has been reported hesitancy over vaccines, particularly among BAME staff. Read full story Source: The Independent, 9 March 2021
  9. Content Article
    Health services in college and university campuses are under pressure to respond to COVID-19 with patient safety in mind. This article  from Abelson et al. in The Seattle Times discusses weakness in university health services that undermine their ability to do so. It shares interviews with students that discuss misdiagnosis and diagnostic delays due to the impact of the pandemic.
  10. Content Article
    While COVID-19 coverage has been saturated with news of clinical cases, deaths, hospital shortages, and financial losses, it seems as though a key population has been excluded from the concern. The youth and young adult population, of all ethnicities and backgrounds, have not had the proper attention to their needs as other groups impacted by COVID-19 have. Particularly, these populations are at risk of severe mental health distress due to COVID-19 related financial, academic, and housing instability.
  11. Content Article
    Tips, advice and guidance on where you can get support for your mental health during the coronavirus (COVID-19) pandemic. If you’re worried about the impact of coronavirus on your mental health, you are not alone. The COVID-19 pandemic is a new and uncertain time for all of us and will affect our mental health in different ways. However you are feeling right now is valid. With the right help and support, we can get through this. Here is you will find advice from Young Minds on things you can do to keep mentally healthy during this time.  
  12. Content Article
    A Parliamentary and Health Service Ombudsman (PHSO) report of an investigation that found that Averil Hart's tragic death from anorexia would have been avoided if the NHS had cared for her appropriately. Ignoring the alarms: How NHS eating disorder services are failing patients highlights five areas of focus to improve eating disorder services.
  13. News Article
    A woman described as a "high risk" anorexia patient faced delays in treatment after moving to university, an inquest has heard. Madeline Wallace, 18, from Cambridgeshire, was told there could be a six-week delay in her seeing a specialist after moving to Edinburgh. The student "struggled" while at university and a coroner said there appeared to be a "gap" in her care. Ms Wallace died on 9 January 2018 due to complications from sepsis. A parliamentary health service ombudsman report into her death was being written at the time of Ms Wallace's treatment in 2017 and issues raised included moving from one provider to another and higher education. Coroner Sean Horstead said Ms Wallace only had one dietician meeting in three months, despite meal preparation and planning being an area of anxiety she had raised. Dr Hazel said she had tried to make arrangements with the Cullen Centre in Edinburgh in April 2017 but had been told to call back in August. The Cullen Centre said it could only accept her as a patient after she registered with a GP and that an appointment could take up to six weeks from that point. Read full story Source: BBC News, 10 February 2020
  14. Content Article
    Although not formally recognised in the Diagnostic and Statistical Manual, awareness about orthorexia is on the rise. The term ‘orthorexia’ was coined in 1998 and means an obsession with proper or ‘healthful’ eating. Although being aware of and concerned with the nutritional quality of the food you eat isn’t a problem in and of itself, people with orthorexia become so fixated on so-called ‘healthy eating’ that they actually damage their own well-being. Without formal diagnostic criteria, it’s difficult to get an estimate on precisely how many people have orthorexia, and whether it’s a stand-alone eating disorder, a type of existing eating disorder like anorexia, or a form of obsessive-compulsive disorder. Studies have shown that many individuals with orthorexia also have obsessive-compulsive disorder. This web page describes: The signs and symptoms of orthorexia Health implications Treatment
  15. News Article
    A coroner has criticised health professionals for failing to give a young woman who died after suffering severe anorexia the support and care she needed. Maria Jakes, 24, died of multiple organ failure in September 2018 after struggling for years with the eating disorder. Coroner Sean Horstead last week concluded that the agencies involved in the Peterborough waitress’s care missed several key opportunities to monitor her illness properly. Mr Horstead said that there had been insufficient record-keeping and a failure to notify eating disorder specialists in the weeks before her death, following treatment at Addenbrooke’s and Peterborough City Hospital. He also criticised the lack of specialist eating disorder dieticians at Addenbrookes and Peterborough hospitals, “together with a nursing team insufficiently trained and knowledgeable of eating disorder patients”, both of which had contributed to the lack of monitoring of Maria. Despite the criticism the father of another anorexia victim, whose death was described in a Parliamentary and Health Service Ombudsman’s report as an “avoidable tragedy”, has said the inquest failed to properly address or challenge the “lack of care” that Maria received from the NHS. Nic Hart, whose daughter Averil died in 2012 at the age of 19, criticised the inquest as “a very one sided process”. He told The Telegraph: “No real challengers were made of the clinical evidence or indeed of the lack of care that poor Maria received.” Read full story Source: The Telegraph, 21 December 2019
  16. Content Article
    NHS investigators are to meet the family of a young, autistic man - left starving and desperately thirsty in hospital while waiting for a delayed operation. Mark Stuart spent five days in agony and died following a catalogue of failings by NHS staff. His parents say they have been battling for answers for four years.  These are the harrowing events that came days before the needless, avoidable death of Mark Stuart. Mark was a young man with autism.
  17. Content Article
    Homerton University Hospital describes how they have embedded the Redthread Youth Violence Intervention Programme into their A&E department.
  18. Content Article
    NHS England published an independent report into the deaths of people with a learning disability or mental health problem at Southern Health NHS Foundation Trust and highlighted a system-wide response. The report was commissioned by NHS England (South) following the death of Connor Sparrowhawk in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust. Both Southern Health NHS Foundation Trust and the clinical commissioning groups (CCGs) that commission services from them have accepted the recommendations.
  19. Content Article
    A thought-provoking blog about what it's like nursing in the emergency department (ED) when there are no beds. 
  20. Content Article
    This blog has been written by a healthcare worker and demonstrates the reality of what it is like caring for patients and families while being chronically low on staff. They describe the impact this has on staff morale and the impact it has on patients, patients family members and the relationship between staff and patients.
  21. Content Article
    The Parliamentary and Health Service Ombudsman (PHSO) has published a report following investigations into the deaths of two vulnerable young men. They found a series of significant failings in their mental health care and treatment.  The PHSO are publishing the report and recommendations to alert parliament to systemic problems in care and treatment of patients with acute mental health problems at former North Essex Partnership University NHS Foundation Trust. NHS Improvement has agreed to establish a review in line with our recommendations and will share any learning it identifies across the NHS as needed. The North Essex Partnership University NHS Foundation Trust (now merged into the Essex Partnership University NHS Foundation Trust) has accepted the recommendations and are committed to continuing to work the PHSO to put things right. It is important the NHS understands why this happened and what lessons can be learned to prevent it happening again.
  22. Content Article
    Patient Safety Learning speaks to sepsis survivor, Dave Carson, and his wife, Margaret Carson, who tell us how things have improved and what more still needs to be done for sepsis.
  23. Content Article
    The preventable death of Connor Sparrowhawk in July 2013 led to a number of investigations and enquiries into practice at Southern Health NHS Foundation Trust in whose care he died.
  24. Content Article
    Sepsis is the immune system’s overreaction to an infection. Normally, our immune system helps fight infections – but sometimes it attacks our body’s own organs and tissues. We do not yet know why the body reacts this way, which is what makes sepsis so dangerous; if Sepsis isn’t treated immediately, it can result in organ failure and death. Yet with early diagnosis, it can be treated with antibiotics.
  25. Content Article
    England’s 15 Patient Safety Collaboratives (PSCs) play an essential role in identifying and spreading safer care initiatives from within the NHS and industry, ensuring these are shared and implemented throughout the system. The PSC is a joint initiative, funded and nationally coordinated by NHS Improvement, with the regional PSCs organised and delivered locally by the Academic Health Science Networks (AHSNs).
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